Abstract
When an accident which harms someone or damages something occurs in this country, the police start an investigation, identify the individuals responsible, and send them to criminal court. This paper describes some recent court cases concerning accidents caused by human error, and posits that judging errors by their consequences will damage rather than contribute, to public safety. From the lessons of the Tohoku earthquake in 2011, we have learned the importance of flexible reactions - responses that are not written in a manual or those that may go against prescribed rules - to situations as they occur. One component of the safety culture is the “flexible culture”, closely related to resilience engineering, which is a noteworthy paradigm in human factors. We conclude that a “just culture”, where practitioners including healthcare professionals are not punished based on the consequences of human error, is the basis for the flexibility and resilience of both organizations and practitioners.
